Injury to the anterior cruciate ligament usually happens when the knee is twisted whilst the foot is static (during a change in direction whilst running, for example; or during a fall when skiing, when the ski remains attached to the ski boot).

The patient may experience an audible pop or crack, an immediate feeling of instability, considerable pain and an inability to place their weight on their foot. Sometimes the immediate symptoms are mild, but the knee will always swell up within days. It’s important to see a doctor as quickly as possible after any kind of knock or heavy contact which results in a swollen knee in order to ensure that a ligament injury is not left untreated.

An x-ray will usually be performed to make sure that no knee fracture has occurred – this would require another kind of treatment.

Injury to the anterior cruciate ligamentis diagnosed by means of a clinical examination and confirmed by an MRI scan, which also looks at the state of the other knee ligaments, the menisci and the severity of the bone bruise.

Why is it important to have any injury to the Anterior Cruciate Ligament diagnosed as quickly as possible?

Following a partial or complete tear of the anterior cruciate ligament, the patient’s knee will usually recover its mobility in 6 to 12 weeks and the associated pain will disappear. This time period depends on the extent of the bone bruise (a hematoma on the tibia and femur following an impact or knock). If the process of rehabilitation is begun soon after the injury, this often helps speed up the recovery of day-to-day knee function. The recovery of knee function does not necessarily apply to knee stability. It is not uncommon for patients to think they have made good progress and to injure themselves again even with a slight twisting of their knee. The main function of the anterior cruciate ligament is to provide stability to the knee joint during twisting movements. Once the anterior cruciate ligament injury has been diagnosed, some low impact activities such as cycling may be allowed, but all pivoting sports must be avoided as these can lead to excessive joint mobility which could make the initial injury worse, especially with regard to the menisci and cartilage, which could cause arthritis in the future.

An ACL injury exhibiting knee instability, if left untreated, is very likely to lead to damage to the menisci and cartilage which can lead to arthritis.

Anterior Cruciate Ligament (ACL) reconstruction.

Following an injury to the anterior cruciate ligament, if the knee exhibits ligamentous laxity and instability, or if you play pivoting sports, your surgeon may suggest you undergo surgery with a view to anterior cruciate ligamentreconstructionto prevent you from injuring yourself again and aggravating the damage to your knee.

It is important to carry out this procedure on a knee which has recovered its full range of motion and is as pain-free as possible, in order to ensure rapid recovery after surgery.

This surgical procedures consists of a surgical graft to replace the damaged anterior cruciate ligament. A piece of hamstring tendon is introduced through a small incision on the front of the knee and attached to the tibia and femur via tunnels in the bone, replacing the damaged fibres of your anterior cruciate ligament. The whole operation is performed by means of arthroscopy, in other words, with a camera introduced inside the knee. This makes it possible for the surgeon to work with greater precision, speeds up the recovery process and causes less scarring (only 3 small incisions are made to the front of the knee).

The patient must see the doctor in their consulting room at ICOS in order for the diagnosis to be confirmed and the surgical approach chosen.

The surgical procedure takes place in the Juge Clinic, located close to the consulting room. This clinic is part of one of the largest specialist knee surgery and ACL reconstruction centres in the country.

The operation may be carried out in the day surgery unit, with the patient going to the Juge Clinic in the morning for their operation and being discharged from the clinic in the evening.

The procedure usually lasts less than an hour and is carried out under general anesthetic.

After surgery, a knee cold compression wrap (Game Ready) will be fitted in the recovery room in order to reduce the likelihood of swelling and hematoma. This will also reduce pain.

When you return to your room, you’ll be served a light meal and you’ll be able to sit up with the help of a nurse. You will normally be able to place your foot on the ground with the support of two crutches.

The surgeon and the anaesthetist will come and see you in your room to give you any relevant advice and instructions and, in most cases, to discharge you from the clinic.

After the operation: post-operative medication and rehabilitation

It’s important to take the medication you’ve been prescribed and to perform the exercises recommended to you.

When you leave the clinic, you will have:

A prescription (pain-killers, anticoagulants to reduce the risk of blood clots), a prescription for a rehabilitation program, delivered by a physiotherapist, and a prescription for at-home nursing care (applying a new dressing and injecting the anticoagulant every day for 2 weeks).

It is important to ice the knee and keep the lower limb elevated in the days following the operation. This will reduce bruising and post-operative pain.

The nurse must regularly change the dressing and we recommend that you go to see your GP a week after the operation to ensure there are no post-operative complications.

Next, the process of rehabilitation will take several months. It will be overseen by a physiotherapist following a clearly-defined program.

In most cases, the patient will no longer need to rely on crutches after about the third week after the operation. You may drive a vehicle once you can walk without crutches and without limping.

The first goal of rehabilitation is to be capable of fully extending (‘locking-out’) your knee, in other words, you achieve a straight-knee position with the quadriceps contracting properly.

The speed at which you will be able to get back to work will depend on the nature of your job and the methods of transportation you use to commute to work and in the course of your work (generally 1 to 3 months after the operation).

Possible complications following knee ligament surgery

Most common complications

As in all surgical procedures, there is a risk of bruising. Bruises generally disappear of their own accord. The best way of treating bruising is still to elevate the lower limb and to regularly apply an ice pack. Very occasionally a tap or a surgical drain may be required.

Blood clots can occur even when anticoagulants are administered. Blood clots can form in the veins of the legs. These could travel to the lungs and thus cause a pulmonary embolism. You will be prescribed a two week-long course of anticoagulants after your operation as a preventive measure.

Less common complications

Scar tissue (adhesions) in the knee joint may reduce the knee’s range of motion and lead to stiffness.

Complex regional pain syndrome is a painful inflammatory disorder which is as yet little-understood. It is treated using medication and may persist for several months, (even for years), in which case it requires a specific course of treatment, a special rehabilitation program, para-clinical testing and sometimes a specific pain management plan. This condition can appear with little or no warning and it is extremely difficult to predict how it will develop or what impact it will have.

In order to minimize the likelihood of this condition occurring, it is important to operate upon the knee when it is as pain-free and as mobile as possible. For this reason it is important to wait for some time after the accident before undergoing surgery.

Deep infections is a very rare complication. It may require another operation and the prescription of a long course of antibiotics. It is strongly advised you avoid smoking during the recovery (wound healing) period. Smoking significantly increases the risk of wound infection.

ACL graft rupture is rare but not impossible in the event of another injury sustained during a pivoting movement. It is important to follow your surgeon’s recommendations relating to how long you should wait before taking up sporting activities again.

This is a non-exhaustive list of complications. Other, more unusual complications can occur, generally due to specific circumstances.

The surface wound is healed in 2 weeks and the healing around the graft area is completed after several months. The ‘ligamentization’ process, that is, the time required for the graft to become as strong as the anterior cruciate ligament, varies from 6 months to 1 year after reconstruction surgery.

It is possible to return to sporting activities after a few months – your surgeon will give you a more specific timetable.

The operation should result in a knee which is stable, has recovered its range of motion and which is not causing you pain. You should be able to take up sporting activities again.

You should generally wait 3 months before taking up non-pivoting sports again, whereas you will generally have to wait 8 to 10 months after the operation before playing pivoting sports again.

The success of the operation with regard to eliminating pain and restoring knee stability will also depend on the extent of related injuries (to the menisci and cartilage) observed during the operation.

Anterior Cruciate Ligament reconstruction surgery – in brief

The reconstruction of the anterior cruciate ligament in the knee by means of arthroscopic surgery and the use of a surgical graft taken from the hamstring tendon is a very common procedure in the field of orthopaedic surgery.

Post-operative recovery involves several months of rehabilitation.

A significant improvement may be noted within 3 to 6 weeks.

Patients may gradually take up sporting activities again, subject to the advice of a sports medicine specialist

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